* denotes required field
Middle School Student High School Fresh/Soph High School Junior High School Senior College Student Other
I authorize Portland State University, and those acting pursuant to its authority to:
(a) Record my participation and appearance on videotape or audiotape, in photographs, or in any other recorded medium. I understand that these recordings and statements may be used in any medium, both printed and electronic, for commercial and noncommercial purposes.
(b) Use my name, likeness, voice, statements, and biographical material in connection with recordings.
(c) Exhibit or distribute such recording in whole or part without restrictions or limitations for any educational or promotional purpose, which Portland State University and those pursuant to its authority, deem appropriate.
I waive any right I might have to inspect and/or approve the finished medium, or the use to which it may be applied.
I represent that I am at least 18 years of age and I have read and fully understood the above paragraph and am knowingly and voluntarily executing this release.
If the individual signing the forgoing is a minor, the following should be signed by his or her guardian; I hereby consent and agree individually and as a parent or legal guardian of the minor who signed above, to all the terms and provisions of said agreement.
Yes No
Informed Consent, Release, Authorization for Event Participation
I hereby assume full responsibility for all risk of injury or loss which may result from my child's voluntary participation in the Human Powered Vehicle National Competition run by Portland State University, Department of Mechanical and Materials Engineering. I understand that the Department of Mechanical and Materials Engineering at Portland State University may provide the opportunity for my child's participation in events that are held at an in-state location. I acknowledge that I have received, read, and understand all the information provided by the Department of Mechanical and Materials Engineering concerning such events, travel arrangements, and hereby approve of my child's participation.
I agree to hold harmless, release and forever discharge the State of Oregon acting by and through its State Board of Higher Education on behalf of Portland State University, its officers, agents and employees from any and all claims and demands whatsoever which I or any third party may have against them by reason of any accident, illness, injury, or death, or damage to, or loss of, or destruction of property arising or resulting directly or indirectly from my child's participation in the event.
I understand, agree and acknowledge that some activities may be of a hazardous nature or may include physical or strenuous activity that may result in illness, personal injury; suffering or death and I understand and appreciate the nature of such hazards and risks. Additionally some activities may require traveling in buses or other approved methods of transportation. Understanding this, to the best of my knowledge, my child has no medical, physical, mental, or emotional health conditions that would hinder his/her participation in the event.
In the case of an emergency, if I cannot be reached, I authorize the staff of the event to obtain whatever medical treatment deemed necessary for the welfare of my child. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether my medical insurance would cover such charges and fees.
I agree that this Consent and Release shall be construed in accordance with the laws of the State of Oregon and that venue for any legal proceeding arising out of this agreement shall be in Oregon. If any term or provisions of this Consent and Release shall be held illegal, unenforceable, or in conflict with any law governing this agreement, the validity of the remaining portions shall not be affected thereby.
I understand that PSU reserves the right to expel my child from the event at any time should his/her actions or behavior, in the sole discretion of PSU, impede or obstruct the activities of other participants in the event or if his/her actions or behavior endanger him/her, other participants, faculty, staff or mentor students.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR THE INJURY OR DEATH OF MY CHILD OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE PROGRAM AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH TO ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY CHILD'S NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
If you experience technical difficulty, please contact Kristen Nieman at krisc@cecs.pdx.edu
